New Minor Patient Form PATIENT INFORMATION (MINOR)Title First Name* Middle Initial Last Name* Preferred Name Date of Birthyyyy/mm/dd Care Card Number Gender Male Female Other Mailing Address* Physical Address City* Province* Postal Code* Country* Home PhoneCellular PhoneSchool Email* PARENT/GUARDIAN INFORMATIONMother PhoneDate of Birth Email Father PhoneDate of Birth Email Guardian PhoneDate of Birth Email IN CASE OF EMERGENCYPlease specify who we should notifyName* Contact Phone*Relationship* GENERAL CONSENTI am the parent, guardian, or personal representative and there are no court orders now in effect that prohibit me from signing this consent. I do hereby request and authorize the dental team at MacKenzie Dental Centre to perform the necessary dental services for the child/minor named above, including but not limited to X-rays and administration of anesthetics, which are deemed advisable by Dr. Philomena Gale and/or Associate(s), whether or not I am present when the treatment is rendered. Terms and Conditions ** I agree*Parent/Guardian Name Dental HistoryReason for your visit Former Dentist Email City & Province PhoneDate of last dental visit Date of last dental radiographs Has minor/child complained about dental problems? Yes No Does minor/child brush twice daily? Yes No Does minor/child use floss daily? Yes No Is fluoride taken in any form? Yes No Have there been any unhappy dental experiences? Yes No Have there been any injuries to the mouth, teeth or head? Yes No Are there any mouth habits, e.g., thumb sucking, nail biting, etc? Yes No MEDICAL HISTORYFamily Doctor Address PhoneReason for visit Date of last visit Please check the box if the minor/child has any history of or difficulty with any of the following:Please check the box if the minor/child has any history of or difficulty with any of the following: Heart problems Heart murmur Congenital heart defect Rheumatic fever Artificial joints Digestion problems Special diet Sinus trouble Asthmas Breathing difficulties Tuberculosis (TB) Tobacco use E-Cigarettes use Chemical dependency Cannabis use Alcohol dependency Blood transfusion Anemia Blood disorder Blood disorder typeBlood disorder type Please check the box Headaches Anxiety Diabetes Thyroid disease Please check the box Cortisone treatments Venereal disease HIV/AIDS Skin rash Allergies/Hives Weight loss Epilepsy Seizures Fainting or dizzy spells Use of contact lenses Liver disease Hepatitis Hepatitis typeHepatitis type Please check the box Jaundice Kidney disease Bladder problems Cancer Chemotherapy Radiation therapy Has the minor/child ever experienced any reactions to dental or general anesthesia? If yes, please describe. Have you ever been advised that the child needs to take antibiotics before dental appointments? Please list any medications, supplements or vitamins that the minor/child is currently taking or is supposed to be taking. Please list any allergies or reactions to any medications or to Latex. Has the minor/child ever had an operation or been hospitalized? Please detail the circumstances and any complications. To the best of my knowledge, the information provided is complete and correct. I understand that it is my responsibility to inform Dr. Philomena Gale and/or Associate(s) if my minor/child ever has a change in health.* yesI have read the terms and conditions, cancellation policy, payment policy, and personal information policy, and I understand my responsibilities as a patient.* yesParent/Guardian Name Insurance InformationDo you have dental insurance coverage for the child? Yes No If coverage is on the same plan as the parent/guardian, please specify dependant number If Insurance coverage is different, please complete the following:Subscriber Insurance Co. Relationship to Patient/Child Group/Policy# Subscriber’s Date of Birth ID/Cert. # Subscriber’s Employer Notes Subscriber Insurance Co. Relationship to Patient/Child Group/Policy# Subscriber’s Date of Birth ID/Cert. # Subscriber’s Employer NotesINSURANCE ASSIGNMENT AND RELEASE I certify that my dependent has dental insurance with the above named Company(ies) and assign directly to Dr. Philomena Gale Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. It is my responsibility to notify the dental office of any insurance coverage changes. I authorize the use of my signature on all insurance submissions. Dr. Philomena Gale Inc. may use my minor/child’s health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when the minor/child ceases to be a patient of this dental practice. Terms and Conditions** I agree Δ
